Thoracoscopic Transmyocardial Laser Revascularization
Keith Horvath
espite tile success of treating coronary artery disease
D with conventional methods, such as coronary ar-
tery bypass grafting (CABG) and pcrcutancous trans-
coronary-an~oplasty (PTCA) with stenting, a si~fificant
and gTOWhlgnumber of patients have exhausted the abil-
ity to repeatedly tmdergo these procedures, primarily
because of tile diffuse nature of their coronary artery
disease. As a restdt of this severe coronary artery disease,
they have chronic disabling anghm that is refractory to
medical therapy. Transmyocardial laser revascldariza-
tion (TMR) has been developed to treat these lmticnts.
Ahhough Mirhoseilfi~,2 and Okada 3 used a laser to per-
form tiffs type of revascularization in conjunction ~dth
coronary artery bypass gu'afting ill the early 1980s, the use
of a laser as sole therapy reqtfired advancements in the
technolo~,. After hnprovements in tile laser that allowed
carbon dioxide TMR to be performed on a beating heart,
restdts from individual hlstitutions1,5 and from mtdti cen-
ter trials 6-8 in 1995 through 1997 demonstrated a dra-
matic hnprovement in the symptomatic relief of an~na,
both short-term and beyond five years9.
As a result of the success of the procedure, TMR has
obtained FDA approval and has been performed on
132 Operative Techniques ill 'Fhq*racic and Cardiovascular Surgery, Vol 6, No 3 (August), 2 0 0 1 : pp 132o139
more than 6,000 patients around tile world. Typically,
tile procedure involves a limited left anterior thoracot-
omy with exposure of tile left ventricle through this
incision. Tile thoracotomy typically is 18 to 20 cm in tile
fifth intercostal space. Through this large incision, tile
l~ericardinm is opened, and tile left ventricular free
wall is drilled with a laser. Tile l-ram channels are
created in a distribution of 1 cm, after which most
patients are extubatcd in the operating room. Occa-
sionally, tile difticuhy in recovering from a thoracot-
omy has also increased the patient's length of stay. The
average length of stay for this procedure is seven or
eight days. 4-a Because the revascularization achieved
by TMR is not immediate, and because postoperative
pain managemcllt is tints critical in reducing the mor-
bidity of the procedure, we have developed a method of
perfornfing tile operation in a less-invasive fashion with
videoseopic assistance. This minimally invasive tech-
nique uses a thorascope, standard instrumentation,
and the same laser equipment as nsed to perform TMR
via a thoracotomy. I have previously described tile
performance of thorascopic TMR in both an animal
model and in treating patients.W.n
TIIORACOSCOIqC TMR 133

S U R G I C A l , TECHNIQUE

Line of
incision in /-
5th intercostal
space for
open TMR
.

/,
/

/
/ /

1 Transmyoeardial laser revascularization 1)erformed as an open surgical procedure is typically

,lone through a left anterolateral thoracotomy in tile fifth intercostal SlmCe. Tile patient is placed
ill a supine 1,osition with a roll under tile left side from tile shouhler to the waist to elevate tile left
llemitllorax. Skin prelmration includes at least one or both groins, lmrticularly in patients with low
ejection fractions or unstable angina, who may require intraoperative placement of an intra-aortic
balloon pump. After adequate general endotracheal anesthesia is established, all 8- to 12- cm skin
incision is made as shown. Tips for general anesthesia inclnde using a ,louble-lumen tube or a
broncllial blocker to isolate tile left lung and using a thoracic el,idural catheter to provide
postol)erative 1)ain control. Exposure of tile heart through this incision typically call be achieved
without division of tile ribs or costal cartilages.
134 KEITII IIORVAT

Open TMR
Laser handpiece

Laser chan,,~,o
in leftventricle

2 Once the ribs are spread by a retractor and tile lung is deflated, the pericardium is opened
to expose tile epieardial surface of tile heart. Care must be taken to avoid previous bylmss grafts.
Tile left anterior descending artery is identified and used as a l a n d m a r k for locating the septum.
The inferior and posterior lateral portions of the heart can be reached through this incision with
a combination of nmnual traction and placement of packing behind the heart and, as illustrated,
the use of a right-angled laser lmudpiece. Channels are created starting n e a r the base of the
heart and then serially i n a line alJproximately one em a p a r t toward the apex, beginning
inferiorly and then working superiorly to the anterior surface of the heart. Because there is some
bleeding from the channels, starting the TMR inferiorly keeps the anterior area clear and
expedites the procedure. The n u m b e r of channels created ,lepends on the size of the heart and
on the size of the ischemie area. Myocardinm that is tlfinned by scar, particularly when the sear
is transmural, should be avoide,l, because TMR will be of no benefit to these re~ons, and
bleeding from channels in these areas nmy be problematic. Trausesophageal echocardiography
(TEE) shouhl be used to confirm transmural penetration of the laser energy. Vaporization of
blood by the laser energy as the laser beam enters the ventricle creates an obvious and
characteristic acoustic effect as noted on TEE.
TIIOILtCOSCOPIC TMR 135

Triangulated intercostal placement of

thoracoscopic tools for TMR

,?'i

9/
!' \,

Thoracoscope with grasper

in 5th intercostal space

3 To minimize postoperative incisional pain, lmrtieularly in patients who have not had previous
bypass surgery, the TMR procedure can be performed with video-assisted thoracoscopy. Again, the
patient is positioned supine with the left hemithorax elevated by a roll. The left upper extremity may
also be retracted cranially to facilitate thoracoscope placement. The thoracoscopic ports may be
placed in the fifth or the fourth intercostal space. Through the same 10-ram port incision used for the
thoracoscope, an endoscopic grasper may be placed to facilitate the dissection. Once the camera has
been placed, additional ports can be created under thoracoscopic guidance. Because the heart is
immediately adjacent to the chest wall, endoscopic instrnmentation may not be necessary, and
standard instruments may be introduced through these additional incisions. The incisions should be
triangulated to provide maxinmm facility for dissection and exposure.
136 KEITI! IIORVATII

Incision of pericardium
over left ventricle

eft
mg

Lef
phr
ner

4 This is tile view from the thoracoscopc showing tile grasper, which is
placed through tile same thoracoscope incision at six o'clock on this
picture, and an additional grasper placed through a third intercostal
incision port at one o'clock. These two graspers are used to elevate and
selmrate tile l~ericardimn, which is divided using standard dissecting scis-
sors placed through a more anterior fifth intercostal incision. Care is taken
to avoid the left phrenic nerve during this dissection.
TIIOIIACOSCOI'ICTMR 137

Laser handpiece on left ventricle

5 Laser handlficces can be introduced through any of tile ports

with replacement of the thoracoscope as needed to allow the creation
of TMR channels oil all areas of the left ventrieular surface. Ilere a
straight handpiece is being introduced through tile third intercostal
incision. Using a combination of straight and right-angled hand-
pieces, all surfaces can be covered. Bleeding from the channels is
controlled with either direct finger pressure or a sponge stick placed
after the handpiece is removed.
138 KEITII IIORVATII

Procedure completed with closure and

drainage of thoracic wounds

,\

/
.1 .r f . 9 9 , " ~ '

O t
i

./
/
i
/

6 Tile thorascoi)ic incisions are closed with three layers of absorbable suture, and a dry sterile
dressing is al)i)lied. A chest tube is placed through one of the fifth intercostal incision sites to
provide adequate postoperative evacuation of air and/or fluid from tile pleural cavity.
TIIOHACOSCOPIC TMR
Collllllent
Minimally invasive procedures have been used in other
lncthods of revascularization, and it, seems appropriate
to use these techniques for patients undergoing TMR.
Because coronary artery disease in these patients is by
detinition more severe than that in patients undergoing
bypass procedures, postoperative pain control and
concomitant respiratory therapy are of critical impor-
tance. This procedure can be done easily without ad-
ditional instrumentation. It is obviously most appropri-
ate for patients who have not had previous CABG. It
may also be performed in conjunction with nfinimally
invasive off-pump bylmss surgery. Placement of an
initial camera port in the lateral fifth intercostal space
in all patients, regardless of previous procedures, will
allow the surgeon to determine whether it will be fea-
sible to perform the procedure thoracoseopieally or
whether it will be necessary to extend the incision
anteriorly and perform the operation through a thora-
eotomy. The anterior fifth intercostal port incision
can also be used as the chest tube site for the thoraco-
seopic procedure. The described thoraeoscopie ap-
proach permits the same transmural revascularization
as is achieved through a thoracotomy and has provided
the same an~na relief for patients.
REFERENCES
1. Mirhoseini M, Cayton M: Revaseularization of the heart by laser. J
Microsurg 2:253-260, 1981
139
2. Mirhoseini 5I, Shel~kar S, Cayton MM: New concepts in revascular-
izatiou of the myocardium. Ann Thorac Surg ,15:.115-120, 1988
3. Okada M, Ikuta II, Shimizu K, et al: Ahernative method of myocardial
revascularization by laser: exl)erimcntal anti clinical study. Kobe J Meal
Sei 32:151-161, 1986
4. Frazier 0II, Cooley DA, Kadipasaoglu IG~., et al: Myocardial revaseu-
larization with laser: preliminary findings. Circulation 92:II-58-II-65,
1995
5. Ilorvath KA, Maunting F, Cummings N, et al: Transmyoeardial laser
revaseularization: Operative techniques and clinical results at two
years. J Thorac Cardiovasc Snrg 111:1017-1053, 1996
6. Vincent JG, Bardos P, Kruse J, et al: End stage coronary artery disease
treated with the transmyocardial CO z laser revascularization: A chance
for the "inoperable" patient. Eur J Cardiothorae Surg 121:888-891,
1997
7. Ilorvath I~,, Cohn LII, Cooley DA, et al: Transmyocardiai laser re-
vascularization: results of a muhieentcr trial with transmyoeardial laser
revaseularization used as sole therapy for end-stage coronary artery
disease. J Thorac Cardiovasc Surg 113:615-651, 1997
8. Dowling RD, Petraeek MR, Selinger SL, et al: Trausmyocardiai revas-
eularization in patients with refractory, unstable an~na. Circulation
98:II-73-II-76, 1998
9. IIorvath I~$, Aranki SA, Cohn LII, et al: Sustained au~na relief five
)ears after transmyocardial revascnlarizatiou with a CO z laser. Circu-
lation 102:II-761, 2000
10. DeGuzmau BJ, Lautz DB, Chert FY, et al: ThoracoscolfiC trausmyocar-
dial laser revascularization. Ann Thorae Surg 61:171-174, 1997
11. llorvath I~,: Thoracoscopic transmyoeardial laser revaseularization.
Ann Thorac Surg 65:1439-1,111, 1998
From the Division of Cardiothoraeic Surgery, Northwestern University Medical
School, Chicago, IL.
Address reprint requests to Keith llor,'ath, MD, 201 E. lluron Street, Suite
10-105, Chicago, IL 60611.
Copyright 9 2001 by W.B. Saunders Company
1522 -2942/01/0603-0002535.00/0
doi:l 0.1053/otct.2001.23223